Critical Care Competency Self Assessment
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1 Critical Care Competency Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date General Skills Advanced directives Patient/family teaching Restrictive devices (restraints) Lift/transfer devices Specialty beds End of life care/palliative care Wound assessment & care Automated Medication Dispensing System, Pyxis, Omnicell, or other Bar coding for medication administration Diabetic care and education Blood Glucose Monitor (BGM) Cardioversion/defibrillation Electronic ICU National Patient Safety Goals Accurate patient identification Effective communication Interpretation & communication of lab values Medication administration Medication reconciliation Labeling (medications & specimens) Anticoagulation therapy Monitoring conscious sedation Pain assessment & management Infection control Universal precautions Isolation Minimize risk for falls Prevention of pressure ulcers Use of rapid response teams Awareness of HCAHPS Cross Country Healthcare, Inc. Rev. 09/12 F0015 Critical Care 1 of 7
2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Cardiovascular Assessment of heart sounds Interpretation of arrhythmias Performing 12 lead EKG s Interpretation of 12 lead EKG Interpretation of hemodynamic monitoring Assist with Insertion & Management of: CVC (Central Venous Catheter) Arterial line Swanz Ganz catheter Flow trac or Vigileo monitoring caths Intra-Aortic Balloon Pump (IABP) Ventricular Assist Device (LVAD, RVAD) Maintenance & Management of: Permanent pacemakers Implantable Cardioverter Defibrillator (ICD) External pacemakers Epicardial pacemaker wires Discontinuing venous/arterial sheaths Femostop/vasoseal Care of Patients with: Acute myocardial infarction Pre/post: cardiac catheterization Congestive heart failure Cardiomyopathy Dysrhythmias/conduction disturbances Aortic aneurysm Thoracic/abdominal surgery Endoluminal graft Cardiogenic shock Hypertensive crisis Pericarditis/endocarditis MAZE procedure Post open heart (CABG/valve) Cardiac contusion/trauma Heart transplant Cardiac tamponade ACLS medications and protocols Antidysrythmics Cross Country Healthcare, Inc. Rev. 09/12 F0015 Critical Care 2 of 7
3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Cardiovascular - cont. Antihypertensives Vasoactive/vasopressor agents Anesthetics (propofol/presedex) Thrombolytics (retavase/activase) Platelet inhibitors (ReoPro/Integrilin/Aggrastat) Flolan for pulmonary hypertension Pulmonary Assessment of breath sounds Airway Management, Care & Maintenance of: Oral/NT/ET airway Tracheostomy Arterial blood gas analysis/interpretation Obtaining ABG blood sample/arterial line Pulse oximetry Ventilator Management BiPAP (Bi-level Positive Airway Pressure) Oscillation/high-frequency ventilation Nitric Interpretation of weaning parameters Maintenance & management of pleural chest tubes Care of Patient with: Acute respiratory failure Adult Respiratory Distress Syndrome (ARDS) Sudden Inflammation Respiratory Syndrome (SIRS) Inhalation injuries Pneumonia Pulmonary edema Near drowning Chronic Obstructive Pulmonary Disease (COPD) Pre/post thoracic surgery Pulmonary embolism Pulmonary/chest trauma Pulmonary hypertension Status asthmaticus Rapid sequence intubation drugs/protocols Nebulizer treatments: Ventolin, Atrovent Cross Country Healthcare, Inc. Rev. 09/12 F0015 Critical Care 3 of 7
4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Neurology Cranial nerve assessment Glasgow coma scale NIH stroke scale NIH stroke certification Seizure precautions Skeletal traction Cervical spine precautions/logroll positioning Halo vest/halo traction Monitoring of neuromuscular blocking agents/paralytics Assist with lumbar puncture Intracranial/Cerebral Perfusion Pressure Monitoring (ICP/CPP) via: Ventriculostomy Subarachnoid screw/bolt Care of Patients with: Lumbar drains Cerebral aneurysm Subarachnoid hemorrhage Status epilepticus TBI (Traumatic Brain Injury) Spinal cord injury CerebroVascular Accident (CVA) Pre/post cranial surgery Meningitis Myasthenia gravis Clipping and/or coilings of aneurysms Pituitary Tumor Steroids: Decadron, Solu-Medrol Anticonvulsants: Dilantin, phenobarbital Paralytic Agents: Norcuron, Pavalon, Nimbex, Tracrium, vecuronium Mannitol Antipsychotics: Haldol Trauma & Burns Mass casualty Electrocution Amputation Gangrene Multiple fractures Cross Country Healthcare, Inc. Rev. 09/12 F0015 Critical Care 4 of 7
5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Trauma & Burns - cont. Thermoregulation: hypothermia/hyperthermia Burns: Calculation of Total Body Surface Area (BSA) Berdow Formula/ Rule of Nines Lund and Browder chart Fluid resuscitation Care & management of burns Gastrointestinal Small bore feeding tube insertion (Dobhoff or Keofeed) Nasogastric tube insertion Post pyloric feeding tube insertion Gastric lavage Use of activated charcoal Maintenance of gastric/jejunostomy tube Stoma care Maintenance & management of enteral tube feedings Assisting/monitoring bedside procedures: endo/chest tubes/bronchs/trach insertion/peg tubes Care of Patients with: Abdominal trauma Acute gastrointestinal hemorrhage Esophageal varices Balloon tamponade devices (i.e. Blakemore tube) Peritonitis Acute pancreatitis Bowel obstruction Liver/pancreas transplant Antiemetics: Reglan, Zofran H2 receptor antagonists Renal Foley catheter insertion Suprapubic tube Nephrostomy tube Peritoneal dialysis Continuous Arteriovenous Hemofiltration (CAVHD, CVVHD, SCUF, CRRT) Hemodialysis of the critically ill patient Care of Patient with: Acute renal failure Cross Country Healthcare, Inc. Rev. 09/12 F0015 Critical Care 5 of 7
6 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Renal - cont. Chronic renal failure AV fistulas, shunts & dialysis catheters Nephrectomy Renal transplant Renal/urinary tract trauma Endocrine Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK) Diabetes Insipidus (DI) Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Administration & monitoring of insulin infusion Use of Endo tool Intravenous Management Starting peripheral IV s Care of patient with Peripherally-Inserted Central Catheter (PICC) Administration/monitoring of Total Parenteral Nutrition (TPN) Administration of blood/blood products Administration of narcotics/sedatives: (fentanyl, Valium, Ativan, Versed, morphine) Bispectral monitoring Tele-ICU (ICU-E) Mentoring Communication Video assessment Utilize tele-icu system Multi-tasking Troubleshoot equipment Giving directions over AV system Interpretation of data Critical thinking Diplomacy Cross Country Healthcare, Inc. Rev. 09/12 F0015 Critical Care 6 of 7
7 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Other Drug or chemical overdose (TCA, ethanol, ASA) Poisoning (CO, cyanide) Substance abuse (ETOH, stimulants, narcotics) Human Immunodeficiency Virus (HIV) Multisystem Organ Dysfunction Syndrome (MODS) Anaphylaxis Disseminated Intravascular Coagulation (DIC) Septic shock Cancer Administration of chemotherapy Monitoring of chemotherapy (does not initiate) Hyperbaric oxygenation Organ/tissue donation procedures Suicide precautions Age Specific Competencies Adolescent (ages years) Young adult (ages years) Adult (ages years) Older adult (ages years) Elderly (ages 80+ years) Please list any Additional Skills: Additional training: Additional equipment: Fax to: The information on this and all preceding pages is true and correct. Signature Date 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0015 Critical Care 7 of 7
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